he importance of the presence

of lymphoid tissue in the

human pharynx was rec-
ognized as long ago as 1884
by Waldeyer
1
, who described its specific
arrangement as a ring of lymphoid tissue,
now termed Waldeyers ring. The ring com-
prises the nasopharyngeal tonsil (NT), or
adenoid, attached to the roof of the pharynx;
the paired tubal tonsils (TT) situated at the
pharyngeal openings of the Eustachian
tubes; the paired palatine tonsils (PT) pos-
itioned in the oropharynx; and the lingual
tonsil (LT) on the posterior third of the tongue. The mucosae of the
pharynx contain smaller, subepithelial collections of lymphoid tis-
sue, which complete the circular band (Fig. 1).
The tonsils are secondary lymphoid organs containing aggre-
gations of lymphoid cells, located in the lamina propria of the phar-
yngeal wall. Similar to Peyers patches and the vermiform appen-
dix, the tonsils belong to mucosa-associated lymphoid tissue
(MALT). The subepithelial, lymphoid compartments of tonsils are
formed by numerous secondary lymphoid follicles (B-cell areas),
surrounded by interfollicular regions (T-cell areas). Tonsils possess
several unique characteristics: (1) unlike the spleen or the lymph
nodes, they are not fully encapsulated; (2) like the spleen but unlike
the lymph nodes, they do not possess afferent lymphatics; (3) like
both the spleen and lymph nodes, they are lymphoreticular struc-
tures, but unlike them, tonsils are also lymphoepithelial organs; and
(4) the tonsillar epithelium not only provides a protective surface
cover but also invaginates and lines the tonsillar crypts.
Tonsillar crypts
Crypts are narrow epithelial diverticula, which considerably in-
crease the available surface area for direct antigenic stimulation. In
an average adult PT the estimated epithelial surface area of the
crypts is 295 cm
2
, in addition to the 45 cm
2
of epithelium covering
the oropharyngeal surface
2
. Thus, crypts are functionally important
features, varying in arrangement from the monocryptic units of the
LT to the polycryptic, sometimes branching crypts of the NT and PT.
In healthy tonsils the openings of the crypts are fissure-like, and the
walls of the lumina are in apposition. In a computerized three-
dimensional reconstruction of the PT crypt system, Abbey and
Kawabata
3
showed that in the centre of the PT are tightly packed
ramified crypts that join with each other, while on the periphery
there is a rather simple and sparse arrangement. Interestingly,
not all secondary lymphoid follicles are in close proximity to the
tonsillar epithelium.
Tonsillar epithelium
The pharyngeal surfaces of the NT and the
TT are covered mainly with a ciliated respi-
ratory epithelium, whereas those of the PT
and LT are protected by stratified squamous
nonkeratinized or parakeratinized epi-
thelium, respectively. These epithelial layers
are avascular and only a very few non-
epithelial cells are found here. The surface
epithelia are underlined by a band of thick
connective tissue containing many vessels,
nerves and lymphatics.
MBy contrast, the epithelia lining the crypts
are not uniform. They contain patches of reticulated, morphologi-
cally reshaped and rearranged strands of epithelial cells, which are
infiltrated with nonepithelial cells (mainly lymphocytes), and are
underlined with disrupted basement membrane but no thick con-
nective tissue band (Fig. 2). The degree of reticulation and lympho-
cytic infiltration varies and is more pronounced in the PT and NT
than in the LT or TT. It is this type of specialized lymphoepi-
thelium that is of functional importance and of renewed interest to
immunologists.
Lymphoepithelium
There are three main components of the lymphoepithelium: (1) the
epithelial cells, which are altered in shape and cellular contents but
which represent a scaffold held together by desmosomes; (2) the
infiltrating, motile nonepithelial cells; and (3) the intraepithelial
vasculature (Fig. 3).
Sthr was the first to suggest that lymphocytes migrated from
the tonsillar parenchyma into the crypt epithelium of the PT
(Ref. 4). The mesh of the epithelial cells was graphically compared
with a sponge with interstices in which it holds the lymphoid
cells
5,6
. Fioretti
7
aptly described the intimate association of epithelial
and lymphoid cells in the crypt epithelium as the lymphoepithelial
symbiosis. The term lymphoepithelium was first used to describe
structures in birds and small mammals by Jolly
8
and first applied to
humans by Schmincke
9
. Reticulation of crypt epithelium is another
commonly used term, introduced by Olah
10
, who found this spe-
cialized lining in most cryptal surfaces. Follicle-associated epi-
thelium (FAE) is another expression, referring to an epithelium that
can sample antigens and translocate them to the underlying lymph-
oid tissue where appropriate clones of T and B cells can be selected
and amplified prior to their migration into the surrounding
mucosa.
Between the epithelial cells with their slender cytoplasmic pro-
cesses, a vast continuum of intercellular spaces is formed, which
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Immunology of the tonsils
Marta Perry and Anthony Whyte
The tonsils are lymphoepithelial
structures that provide a protective
immunological ring at the openings
of both digestive and respiratory
tracts. Here, as discussed by
Marta Perry and Anthony Whyte,
the unique nature of the various
human tonsils reveals that they are
capable of a variety of complex
immunological functions.
T
Copyright 1998 Elsevier Science Ltd. All rights reserved. 0167-5699/98/$19.00 PII: S0167-5699(98)01307-3
is filled with mobile and motile free cells (Fig. 3) such as T cells,
IgG-, IgA- and IgM-producing B cells, macrophages, interdigitating
dendritic cells (IDCs) and Langerhans cells (LCs). Since these cell
types are present in the crypt epithelium as early as week 15 of ges-
tation
11
, it is likely that reticulation is a normal developmental event
and continues throughout life. The infiltrating nonepithelial cells
are therefore considered a physiological characteristic of this epi-
thelium which, postnatally, are constantly exposed to airborne and
alimentary antigens. Any inflammatory changes, with the ad-
ditional presence of polymorphonuclear leukocytes, are superim-
posed onto the normal pattern of reticulation
12
. Studies on human
PT and NT showed that the tonsillar crypt epithelium functions as
an additional lymphoid compartment by contributing to the pro-
duction of immunocytes and to the protection of the mucosal sur-
face
13
; it also provides direct, transepithelial access for antigens. In-
deed, the pioneering work by Brandtzaeg and colleagues strongly
indicates a crucial numerical balance between the epithelial and
nonepithelial cells
14
. To be efficient, the reticulated epithelium needs
to contain not only the immigrant lymphoid cells but also sufficient
epithelial cells, some of which can synthesize secretory component
(SC) or the polymeric Ig receptor (pIgR), which stabilizes and trans-
ports secretory IgA to the mucosal surface
15
. However, other stud-
ies have failed to detect pIgR in either PT or LT (Refs 1618), al-
though some epithelial cells of the NT may express pIgR (Ref. 19).
Epithelia covering surfaces or lining cavities are usually not pen-
etrated by blood vessels and only a few sites in the human body (the
stria vascularis of the cochlea, for example) possess true intraepi-
thelial capillaries. Importantly, within the tonsillar lymphoepi-
thelium, there is a network of intraepithelial blood vessels (Fig. 3).
In both the PT and NT, capillaries are arranged in loops oriented
perpendicularly to the crypt surface, and high endothelial venules
(HEVs) are located in the lower border regions of many reticulated
patches
20,21
(Fig. 2). The rich intraepithelial blood flow provides for
the metabolic needs of this site, as well as increasing the area for in-
teractions between endothelial cells and leukocytes, and the transport
of immunoglobulins and other substances across the vessel walls.
An unusual feature of the lymphoepithelium covering the
lymphoid tissue is the content of cells that are involved in immune
surveillance and effector functions
22
. In the intestine, specialized
epithelial cells with characteristic short microvilli and microfolds on
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Palatine
tonsil
Tubal
tonsil
Lingual tonsil
Adenoid
Fig. 1. Pharyngeal lymphoid tissue of Waldeyers ring comprises the nasopharyngeal tonsil or adenoid (NT), the paired tubal tonsils (TT), the paired
palatine tonsils (PT) and the lingual tonsil (LT). All four micrographs show that the surface of the tonsils is in each case covered with pharyngeal
epithelium. Note the branching crypt arrangement in the NT and the PT, and the single crypt in the LT. The intimate relationship of tonsils with
salivary glands is especially obvious in the TT.
their luminal surface are known as M cells. These are always in
close contact with lymphoid cells but the precise mechanisms of
M-cell function are not fully understood. Their cytoplasmic micro-
pinocytotic vesicles are credited with an exceptional capacity to
trans-cytose a wide range of particulate and soluble material with-
out extensive degradation
23
. In human tonsils, the presence of M
cells is still debated as no probe has yet been identified with speci-
ficity for these cells: rather, they have been described using ultra-
structural criteria alone
24,25
. However, with or without the accep-
tance of the term M cells, the areas of reticulated epithelia in all
human tonsils are functionally similar to the intestinal M cells and
probably also have the ability to act as a portal for antigens, as has
been demonstrated in experimental animals
26
, and transport and
translocate processed antigens to the subepithelial lymphoid tissue.
Evolution and ontogeny
In the human embryo there are six pairs of branchial arches, which
develop on the lateral aspect of the head. Between these arches are
successive endodermal grooves that form the pharyngeal pouches.
This region, containing the primordia of lymphoepithelial organs,
represents the most dynamic part of every embryo. In lower verte-
brates, there is no tonsil but the thymus is present in all pharyngeal
pouches. In man, however, the thymic anlagen reduce to only the
third pouches
2
and aggregations of lymphoid elements infiltrate
the subendodermal pharyngeal mesenchyme as tonsillar anlagen
of Waldeyers ring. These develop in the first pharyngeal pouches
(TT), the second pharyngeal pouches (PT), on the dorsum of the
tongue (LT), and in the dorsal pharyngeal wall (NT). The intimate
relationship of tonsils and salivary glands is
maintained postnatally and is especially no-
ticeable in the NT and TT (Fig. 1).
MBecause of their evolutionary history, it is
not surprising that some common features
are found in both thymus and PT. The
reticulation of the epithelium, with intimate
lymphoepithelial relations, as well as the
ability to form epithelial (Hassalls and ton-
sillar) corpuscles, illustrate the homology
between the thymic stroma and the tonsillar
crypt epithelium
27
.
MImmunohistological and ultrastructural
studies of human fetal PT revealed that: (1)
the mesenchyme underlying the tonsillar
epithelium becomes invaded with lym-
phoblastic B and T cells in the 14th week of
gestation; (2) primary follicles develop at
16 weeks of gestation, which is earlier
than in any other secondary lymphoid
organs; (3) by week 20, the areas surround-
ing the primitive crypts are richly vascu-
larized with capillaries and HEVs; and
(4) similar to the thymic medulla,
T helper cells are in close contact with
IDCs bearing HLA-DR molecules
28
.
Whereas the maximum postnatal growth of the TT and NT is
between four and seven years of age, the PT begin to regress
much later (from the age of 14) and LT involution is shifted to the
fourth decade. These findings may account for the frequency of
nasal breathing problems (obstructive sleep apnoea syndrome) and
glue ear in young school children, which are due to mechanical
obstruction of the pharynx and the openings of the Eustachian
tubes
29
.
Secretory immunoglobulins
IgG, IgA and IgM are detectable in the secretory material from the
pharynx and in pharyngeal roof tissue homogenates as early as
week five of gestation. Since levels of these immunoglobulins in-
crease with fetal age, it has been proposed that the fetal tonsil (NT)
reacts to autoantigens that are produced as a result of cell death dur-
ing morphogenesis
30
.
The mucosa of the pharynx has a complex secretory immune sys-
tem. B cells, which can express J-chain, are stimulated by antigen
initially in regions of MALT, including the tonsils, and the resulting
primed lymphocytes migrate to glandular sites where they differ-
entiate into Ig-producing cells. Most of this Ig is in the form of IgA
polymers that are exported through serous salivary cells by an epi-
thelial receptorprotein complex. Thus, the close anatomical re-
lationship between tonsils and salivary glands has an important
functional significance. A stable complex is dependent upon the
presence of the J-chain in the IgA polymer. J-chain is also present in
IgM, which can therefore be secreted in a similar fashion to IgA. In
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Thickness of the
reticulated epithelium
Crypt lumen
Germinal
centre
Mantle
zone
Interrupted
basement
membrane
3
2
1
HEV
Fig. 2. Lymphoepithelium of the paired palatine tonsils. The nonepithelial cells, mainly lymphocytes,
can enter the reticulated epithelium either via vascular (1 and 2) or nonvascular routes (3). Routes
1 and 2 involve direct homing into the lymphoepithelium through the walls of capillaries and high
endothelial venules (HEVs), whereas route 3 involves entry from the subepithelial lymphoid com-
partments through the disrupted basement membrane.
patients with selective IgA deficiency, secretory IgA (sIgA) is lack-
ing but its function may be replaced by sIgM. In other IgA-deficient
patients the Ig dysfunction results in many IgD-producing cells in
the mucosae. However, IgD cannot be secreted and consequently
such individuals are prone to recurrent respiratory infections. In
addition, in normal tonsils, most memory B cells do not appear to
have surface IgD (Refs 31, 32). A key to successful mucosa protec-
tion lies in the ability of sIgA to prevent adherence of both
bacteria and viruses to pharyngeal epithelium. Because common
pathogens of the upper respiratory tract, such as Haemophilus
influenzae, Streptococcus pneumoniae and Neisseria meningitidis often
produce IgA1-specific proteases, an isotype preferentially produced
as an sIgA, immunomodulation towards production of the sIgA2
isotype may offer potential for future immunotherapy
33
.
Tonsillar leukocytes
Leukocytes, predominantly lymphocytes, are found in all the
compartments of the tonsils, including the lymphoepithelium
(where they are called intraepithelial leukocytes; IELs), the closely-
associated mantle zone, the interfollicular regions, and the follicles.
Populations of T cells, with a natural killer (NK)-cell-like func-
tion due to the perforin complex, occur only in low numbers in ton-
sils, particularly in the lymphoepithelium. The number of IELs in
patients with recurrent tonsillitis is significantly greater than in pa-
tients with idiopathic tonsillar hypertrophy; this is due to a selective
increase in CD8

T cells using the otherwise rare V1/V9

combination
34
.
Approximately 50% of IELs are B cells, which express a wide
variety of markers
22
, including the anti-apoptotic Bcl2 protein, a
proto-oncogene product
35
. Apoptosis of tonsillar B cells may also
be inhibited as their activation does not lead to functional Fas ligand
(FasL) expression, in contrast to T cells. FasL binds the CD95
(APO-1/Fas) antigen and thus mediates activation-induced cell
death
36
. Tonsillar IDCs, when reacting with antigen-specific T cells,
ligate CD40 and become resistant to Fas-induced apoptosis
37
. The
extrafollicular B cells are L-selectin positive, consistent with the
binding of the monoclonal antibody (mAb) MECA-79 (which recog-
nizes the peripheral lymph node addressin) to the tonsillar HEVs
(Refs 38, 39). However, this might suggest that these trafficking lym-
phocytes in the tonsil do not shed L-selectin as do those entering pe-
ripheral lymph nodes. A smaller percentage of tonsillar IELs are
T cells with a greater number of CD4

than CD8

cells, the former

sometimes seen in clusters with B cells
40
. It has been suggested, at
least for the NT, that locally released cytokines downregulate
IL-2 production, resulting in immune suppression in the NT of
children with recurrent otitis media and chronic sinusitis
41
.
Seven human tonsillar B-cell subsets have been phenotyped,
which characterize populations undergoing diverse processes such
as isotype switching, CD40 ligation (a key activation signal for ger-
minal centre B-cell responses) and affinity maturation
32
. In the ger-
minal centres, B cells are either selected to become memory cells or
eliminated by apoptosis. Follicular dendritic cells (FDCs), which
are intimately associated with the germinal centre B cells, are
thought to be important in this process
32
. In fact, only B cells that
are adherent to FDCs remain viable, and the leukocyte function-
associated molecule 1 (LFA-1)intercellular adhesion molecule 1
(ICAM-1), and very late antigen 4 (VLA-4)vascular cell adhesion
molecule 1 (VCAM-1) pathways contribute to B-cell selection
42
. The
lymphocyte maturation marker ecto-5'-nucleotidase (CD73) is one
molecule that has been identified as mediating the adhesion of B
cells to FDCs (Ref. 43). T-cell-derived cytokines probably regulate
FDC stimulation of B-cell proliferation and maturation
44
. Tonsillar
B cells occur predominantly in three sites: in the follicular mantle,
in the germinal centres and as intraepithelial cells
45
. The latter ex-
press high levels of Bcl2 and resemble the B cells of the splenic
marginal zone
46
.
Adhesion molecules and trafficking
Specialized trafficking HEV structures (Fig. 4) are found in both
interfollicular and lymphoepithelial areas
47
. As may be expected
from specimens usually removed for recurrent tonsillitis, a wide
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Fig. 3. Lymphoepithelium of the paired palatine tonsils (PT). In both
micrographs the crypt lumen is at the top. (a) PT is predominantly a B-
cell organ and the numerous follicles are arranged parallel to the crypt
surface. The mantle zone (m) is always facing the crypt and there is no de-
lineation between it and the reticulated epithelium. (b) The sponge-like
arrangement of the epithelial cells creates spaces filled with infiltrating
lymphoid cells. The intraepithelial lymphoid compartment has a honeycomb
of epithelial cells (arrows) filled mainly with lymphocytes (arrowheads).
Note the lumina of the intraepithelial capillaries (double arrows).
number of adhesion molecules have been reported in tonsillar tissue.
The VCAM-1VLA-4 interaction may be particularly important in
the migration of IELs (Ref. 48). Although P-selectin is expressed on
tonsillar HEVs (Fig. 5), its ligand, P-selectin glycoprotein ligand 1
(PSGL-1), is substantially lower on tonsillar lymphocytes than on
circulating lymphocytes, suggesting downregulation on entry into
the tonsils
49
. Tonsillar P-selectin does not react with the MECA-79
mAb, nor does it support L-selectin-mediated lymphocyte rolling
50
.
CD34, however, which is recognized by the MECA-79 mAb, is the
major L-selectin ligand in tonsillar HEV (Ref. 51). Thus CD34 and
its counter-receptor L-selectin are the molecules most likely to be
involved in the entry of naive lymphocytes into the tonsil.
E-selectin is expressed by HEVs within the PT and NT (Fig. 5),
and interestingly the HECA-452 antibody, which recognizes the
cutaneous lymphocyte-associated (CLA) complex, was originally
raised to tonsillar HEVs (Ref. 52). It is not surprising therefore that
tonsillar lymphocytes adhere to activated endothelium in skin
53
, an
observation that may help to explain Palmoplantar pustulosis, a der-
matosis often effectively treated by tonsillectomy. Tonsillar lympho-
cytes have been shown to migrate to other inflamed sites such as
synovium via an LFA-1-dependent mechanism
54
. Vascular adhesion
protein 1 (VAP-1) is selectively expressed in PT, peripheral lymph
node and inflamed synovium, and L-selectin

lymphocytes can
bind to tonsillar HEVs via a VAP-1-mediated pathway
55
.
Several other adhesion proteins have been observed to be active
in the tonsils, in particular LFA-1 and its ligand ICAM-1 (Ref. 47)
(Fig. 4). The expression of both CD31 and CD54 are enhanced on
tonsillar HEVs of patients with IgA nephropathy
56
. Extravasation of
neutrophils during acute inflammatory episodes of the tonsil may
be assisted by disruption of the vascular endothelial cadherin
catenin complex in endothelial cell junctions in the HEVs (Ref. 57).
Immunopathology
In the past, just as today, the anatomical
position of the palatine tonsils made them
accessible for study in health and disease,
and a popular target for surgical interven-
tion. As early as 3000 BC the procedure
known as tonsillectomy was performed by
the Greeks, who gave prominent consider-
ation to diseases of the tonsils and palate
58
.
In the last 100 years the most important
indications for removal of the tonsils in-
cluded hypertrophy, which interfered with
respiration, and chronically inflamed ton-
sils, with or without symptoms of glue ear.
Between the First and Second World Wars,
radical treatment was often advocated with
the result that adenotonsillectomy was
unnecessarily performed on many children.
By contrast, recently, there has been a strong
reaction against the operation, pointing out
the lack of sound scientific basis
59
, es-
pecially with the growing knowledge of the
immunological functions of the tonsils.
As a route of pathogen entry, the tonsils are well known for
postviral infection with bacteria
13
and also the EpsteinBarr virus
60
.
In the pre-antibiotic era, rheumatoid arthritis, gout, endocarditis,
pericarditis, myocarditis, chorea, neuritis, myositis, and acute or
chronic glomerular nephritis were regarded as diseases caused by
the tonsils
61
.
However, even today, tonsillitis is known to play an important
role in the occurrence of secondary diseases in the form of focal in-
fection such as IgA nephropathy (IgAN)
62
, arthropathy
63
and reac-
tive arthritis
64
. All of these diseases have in some cases improved
after tonsillectomy. On immunohistochemical examination, the ton-
sillar lymphoepithelium of the patients with IgAN showed a lack of
reticulation. Moreover, there was a strong correlation between the
extent of nonreticulation and the degree of renal damage, indicating
the functional importance of the tonsillar microenvironment in the
pathogenesis of IgAN (Ref. 62). Compared with control tonsils,
those removed from patients with IgA nephropathy have signifi-
cantly increased numbers of IgA-producing cells and an increase in
the ratio of IgA polymer- (J-chain

) to monomer-producing cells
65
.
Polymeric IgA deposited in the glomerular mesangium of patients
attracts cells of tonsillar origin, leading to the autoimmune compli-
cations of IgAN (Ref. 66). In vitro, significantly less pIgA is pro-
duced by mitogen-stimulated PT from children operated on for re-
current tonsillitis than by those obtained from patients with IgAN
(Ref. 67).
Tonsils as a site for HIV entry and replication
The increasing interest in the role of the tonsils as a possible site of
entry and/or replication of the HIV-1 (AIDS) virus highlights the
unique functional morphology of this tissue. In their pioneering
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Fig. 4. (a) Scanning electron micrograph of a high endothelial venule (HEV) showing the
cobblestone appearance of the high endothelial cells and adherent luminal lymphocytes. (b and c) Im-
munoelectron micrographs illustrating that the firm adhesion of the circulating lymphocytes is fa-
cilitated by the expression of leukocyte function-associated molecule 1 (LFA-1) on their surfaces (b)
and by its ligand, intercellular adhesion molecule 1 (ICAM-1), expressed on the endothelium (c).
studies with access to rare human material, Frankel and co-work-
ers
68,69
examined NT and PT, most of which were removed from pa-
tients with chronic HIV-1 infection who were clinically well. The
authors found cells with strong staining for intracellular HIV-1 Gag
protein located in the epithelium. These cells were multinucleated,
or syncytial, and carried the marker for HIV-1 RNA as well as the
dendritic cell (DC) marker S-100, but not other leukocyte markers.
Interestingly, in all cases, the HIV-1-infected cells were seen in the
epithelium that lines the tonsillar crypts, rather than that which cov-
ers the nasopharyngeal surface of the NT or the oropharyngeal sur-
face of the PT. This important finding illustrates that the morpho-
logical characteristics of the reticulated tonsillar crypt epithelia
provide a functionally dynamic environment, which is very
different from that of the pharyngeal surfaces of the NT and PT.
Thus, the highly specialized region of the lymphoepithelium
provides an excellent microenvironment for epithelialnonepi-
thelial cell interactions, as well as direct transepithelial access for
antigens. Indeed, Frankel
69
commented on the presence of DCs and
T cells in the reticulated crypt epithelium and drew a parallel to
in vitro experiments, in which the replication of HIV-1 is promoted
by both of these cell types. Since very few DC and T cells may be
present in the epithelia covering the pharyngeal aspects of the NT
and PT, it is not surprising that HIV-1-infected cells were not found
in these locations. HIV-1 on FDCs in the secondary follicles of the PT
is likely to be highly infectious
70
. The tonsils therefore appear to
play a major role in the replication of HIV-1 and possibly also act as
a route of infection such as occurs with the EpsteinBarr virus
60
.
Moreover, HIV-1 is present in NT and PT from asymptomatic indi-
viduals
71
and one of the earliest manifestations of HIV-1 infection
is obstructive sleep apnoea caused by hypertrophy of the NT.
Although the importance of the intraepithelial vasculature in the
crypts was not addressed
69
, it may be that its presence is essential
for the maintenance of the metabolically highly active replication
of the HIV-1 virus and for the provision of a
convenient route for direct homing of leuko-
cytes into this compartment (Fig. 2).
Tonsils as a site for entry of other
pathogens
In situ hybridization and immunocyto-
chemical studies have identified measles
virus antigens in various lymphoid sites in-
cluding the tonsils
72
. Tonsils from patients
with measles contain multinucleated giant
WarthinFinkeldey cells, which in certain
cases have been shown to have a T-cell
phenotype
73
.
MThe prion protein (PrP
Sc
), which causes
scrapie in sheep, is consistently present at
high levels in the follicles of the PT of in-
fected animals
74
. Abnormal PrP immuno-
staining occurs in the tonsils of scrapie-
infected sheep long before the appearance
of clinical signs
75
. Tonsillar biopsy has been used to demonstrate the
presence of new-variant CreutzfeldtJakob disease (nvCJD) in hu-
mans
76
, the diagnosis of which is currently only possible after brain
biopsy or at necropsy.
Experimental models
Although inbred strains of mice and rats are readily obtainable, they
are not suitable as models for functional studies of the Waldeyers
ring. They have a very different pharyngeal anatomy to humans
and lack both PT and NT, but they do possess bilateral aggregates
of nasopharyngeal lymphoid tissue
77
. The rabbit has a monocryptic
PT (Ref. 10) and the shrew (Suncus murinus) has a microscopic PT
equivalent, consisting of a single lymphoid follicle
78
. By contrast,
tissues equivalent to Waldeyers ring have been found in
monkeys
79,80
, horses
81
and cattle
82
. However, apart from the pri-
mates, it is only in the omnivorous pig that all the discrete lymphoid
components of the ring (PT, NT, LT and TT) are found
83,84
.
Conclusion
We have focused mostly on the PT and the NT because these are
readily available at adenotonsillectomy and have therefore been
studied in some detail. There is, by comparison, very little pub-
lished work on the human LT and virtually none on the TT. Pharyn-
gitis is a common presentation of lingual tonsillitis, and it may be
that chronic inflammation of the LT is frequent in adults. One study
suggests that the LT is immunologically more active than both PT
and NT during middle-age
85
. Because of the complex and varied im-
munological interactions which occur in the tonsils, frequently af-
fecting distant sites, further studies on these structures will provide
invaluable information not only on fundamental immunological
processes but also on the pathogenesis of a wide variety of diseases.
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Fig. 5. Immunoelectron micrographs of high endothelial venules in the paired palatine tonsils and
nasopharyngeal tonsil showing the expression of (a) P-selectin; (b) E-selectin; and (c) intercellular
adhesion molecule 1 (ICAM-1) on the endothelial cells. By contrast, vascular cell adhesion molecule 1
(VCAM-1) (d) is not found on the endothelium, but is expressed in the subendothelial connective
tissue of the vessel wall (arrows).
Marta Perry is at the Division of Anatomy and Cell Biology, UMDS,
Guys Hospital, London Bridge, London, UK SE1 9RT; Anthony Whyte
(Tony.Whyte@bbsrc.ac.uk) is at the Cellular Immunology Laboratory, The
Babraham Institute, Cambridge, UK CB2 4AT.
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RE VI E W
I MMUNOL OGY TODAY
V o l . 1 9 N o . 9 4 2 1
S E P T E M B E R 1 9 9 8
he marginal zone of the human
spleen is a microanatomical site
containing loosely aggregated
B cells and macrophages, situ-
ated around the mantle zone on the periph-
ery of the splenic white pulp. Marginal-zone
B cells have characteristic morphology: they
are slightly larger than mantle-zone B cells,
and have paler, more-irregular nuclei than
the dense, round nuclei of mantle-zone B cells
(Fig. 1). Marginal-zone B cells in adult
spleen can be discriminated from mantle-
zone B cells most easily by their IgD expres-
sion
1
. Mantle-zone B cells are IgD

whereas
marginal-zone B cells are IgD

or IgD
lo
(Fig. 2). Other antigens that have been reported to identify marginal-
zone B cells include alkaline phosphatase
2
and 4D12 (Fig. 3; Ref. 3),
which are not expressed by mantle-zone B cells; CD21, which is
also expressed, but at lower levels, by mantle-zone B cells
4
; and
CD25, which has been observed by some authors but is not a
consistent finding
1,2,4
.
Marginal-zone B cells in rats do not recirculate
5
. However, lympho-
cyte extravasation into the splenic white pulp of rodents occurs
through the sinusoidal network of the marginal zone. High endo-
thelial venules (HEVs), which mediate the extravasation of recircu-
lating cells into lymph nodes, are absent in the spleen
6
. Although
sinusoidal lining cells express mucosal addressin cell adhesion
molecule 1 (MAdCAM-1), an adhesion molecule involved in
recruitment of lymphoid cells into mucosal
sites, blocking the binding of MAdCAM-1
or its lymphocyte ligand, the
4

7
integrin
complex, failed to alter the pattern of
lymphocyte migration
7
. Marginal-zone
macrophages may be involved in the re-
cruitment of lymphocytes to the splenic
white pulp
8
.
MIt is not possible to extrapolate these ro-
dent experiments directly to man since
there are considerable interspecies differ-
ences in the microanatomy of human and
rodent spleen. Human spleen lacks the mar-
ginal sinus and the architecture of the peri-
arteriolar lymphatic sheath (PALS) is differ-
ent, though MAdCAM-1 expression by sinus lining cells of human
splenic marginal zone has been observed
6,9
. The mechanism of lym-
phocyte entry and the precise route of migration of lymphocytes
through human spleen therefore remains unknown.
Function of splenic marginal-zone B cells
The earliest studies of the function of splenic marginal-zone B cells
in rats highlighted the importance of the marginal zone in the re-
sponse to thymus independent type 2 (TI-2) antigens, such as bac-
terial capsular polysaccharide antigens
10
. Marginal-zone macro-
phages retain TI-2 antigens injected into the blood
11
and, although
there has been some debate over the relative importance of the
Human marginal-zone B cells
Jo Spencer, Marta E. Perry and Deborah K. Dunn-Walters
Marginal-zone B cells are likely to
be the first B cells in lymphoid
tissue to encounter antigen. Here,
Jo Spencer and colleagues review
their distribution, properties and
malignancies, and suggest that they
are designated marginal-zone
B cells because of their phenotype
and location, and that this does not
reflect a specific function, since the
population appears to be functionally
heterogeneous.
PII: S0167-5699(98)01308-5 Copyright 1998 Elsevier Science Ltd. All rights reserved. 0167-5699/98/$19.00
T